Hi folks - I had posted something on LAR surgery a few days ago...continuing to assess things. T2N0M0 clinically tagged. Assessing LAR or Transanal excision. Seems to come down to going with a less invasive surgery with better post op quality of life, but with the unknowns on lymph involvement vs LAR with possible LARS, temp ileostomy, longer recovery road...but with knowing lymph status. If positive, then that is the worry area same as with the unknown worry from excision. Surgeon has discussed both options and seems tied to my tolerance for risk and unknowns. I know LAR is the "standard", but given my stage is it overkill vs doing excision? Surgeon also seems more concerned with distant recurrence than local with either option, especially if LAR with positive lymph. If positive and post op chemo is there still reason to be worried?? Appreciate any input.

If your doctor is suggesting either option to you, has he also suggested having radiation either before or after the excision? If not, and if you are seriously contemplating the excision, I would ONLY go that option IF you have radiation and perhaps even some "chemo-lite" (Xeloda only) afterwards.

If you look at my signature, you will see that I also had an excision...with chemoradiation before as well as some more chemo. There is NO way that I would do an excision just by itself but that's my opinion. Like you, I was very concerned about the quality of life issues and for me, that was a HUGE difference between my protocol (neoadjuvant chemo, excision, chemo) and the standard of care, LAR.

Talk to your doctor....both your surgeon and your onc. Feel comfortable with your decision and if you have an excision, make sure you have thorough and meticulous followups to include rectal ultrasounds to check for potential local lymph node involvement. I don't for a minute regret my decision but I recognize that it isn't for everyone.

Thanks. I forgot to note that I did do chemo/rad already in advance of surgery. Tumor has pretty much disappeared and only scar tissue remaining. Surgeon said if excision they would not do another round of chemo. For me its the worry about not knowing about lymph vs getting a positive hit with LAR and worrying about that. Surgeon said for T2 there is a 25% risk of lymph impacts and even though clear scans they are only about 80% accurate. With that logic I have a 20% error rate on the 25% risk which I think puts me at 5% overall risk for lymph impact. Surgeon also stated that there is only about 5-6 years of data comparing excision to LAR and for now outcomes seems similar from a cancer perspective, but nothing longer term available.

I would still want to know what the follow up would be for the excision route. IF the surgeon isn't advocating for a more thorough followup (than the one for LAR) then I would be very concerned about that. Here is an excerpt from an email that I received from Dr. David Medich (Pittsburgh) in 2007:

"Briefly: there is no reliable way to stage lymph nodes after CRT-we use> response in the rectal wall as a predictor of lymph node status-there> are plenty of studies of radical surgery after CRT that have> demonstrated that lymph node positvity is low (<5%) when there is no> residual tumor in the rectal wall. > > Among patients undergoing LE (we do not do TEM) that have a complete> response >90% are alive and well free of cancer at 5 years-the best data> comes from Brazil-Dr. Angelita Habr-Gama-google her and you will be> quite surprised to see how mature her experience is-I have spent some> time with her and can assure you that she is honest and I believe her> data (she is not uniformly trusted as her data is not independantly> evaluated by US investigators). See also the American College of> Surgeons Oncology Group's website to learn about the current US study> treating cT2 rectal tumors with CRT + LE...progress is being made. DSM">

What I found particularly interesting was something Dr. Medich said in the first paragraph. I later spoke with him at length and made sure that I hadn't misunderstood his comment. He is saying that there are plenty of studies on patients who have had both APR and/or LAR surgery and the correlation between lymph node involvement/residual tumor after chemoradiation (CRT). In my case, my pathology report showed no cancer cells at all.....and although there is no 100% guarantee, with that information, and based on other studies (Dr. Medich confirmed that the studies he was referencing had in excess of 3000 patients....certainly not a small sampling), my chances of having lymph node involvement were low (less than 5%). That was a risk I was comfortable in taking on.

You could always go the route of the excision and see what the pathology report shows. IF the pathology doesn't show the best outcome, you can always opt for the LAR...that's a very viable option. One other thing I would note is this. DO NOT ALLOW THE SURGEON TO DECIDE FOR YOU WHETHER OR NOT YOU NEED OR DON'T NEED MORE CHEMO. Talk to your oncologist about the possibility of chemo after an excision and if you don't have an onc already, GET ONE! A surgeon shouldn't be telling the patient about chemo. It is NOT the surgeon's place nor his/her specialty.

My husband had T2N0M0 rectal cancer also. His tumour was quite high in the rectum so didn't need pre-operative radio or chemo. He wasn't offered an excision. We were told he required a LAR without any other options on the table because it was the only way to assess whether lymph nodes were involved accurately.

The surgery was not smooth for him- he had problems with a bowel obstruction and other complications when it came time for his ileostomy to be reversed. I can only speak as a spouse, but despite all the tough times in the last year, I feel incredibly glad he had the surgery. It has given us the most information (and from my understanding of the studies, the best chance of cure) and removed the what-ifs of not knowing if there was lymph node involvement. His quality of life now is much better- he still has some residual problems with frequent bowel motions but other than that, we are living the life we lived before the diagnosis.

My surgeon gave me the option of both as well . My tumor was 1.3cm in my rectum. I was left with about 2 inches of my rectum left after the surgery and he took about 18 inches of my large intestine and rectum out. It basically came down to "do I want to give myself the best chance for a cure"? Do I want to see my children's milestones in life? I didn't want to mess around with the what ifs. I am super happy with my decision. He did stress that if he did excision and I did have lymph node involvement the cancer could come back anywhere and I could be dead in two years. My life is to important to me. I didn't want to look back at a decision that I regretted making and facing a bigger battle. I do go to the bathroom more often, but it does not effect my life. I drive a semi for ups. I am on the road for 10 hours a day and have not had a disaster issue yet. Look over my signature below.

My surgeon said he would recommend excision over LAR only for patients who would have difficulty tolerating and recovering from surgery such as an elderly person or someone with additional serious health concerns. I wanted to go the excision route, but ultimately decided for ULAR and the associated possibility of LARS in order to provide the lowest probability of recurrence. I have LARS but it is manageable and has been improving with biofeedback and pelvic floor physical therapy.